Management of septic shock in adults

Immediate priorities: first hour

1. Call for senior help and admit to ICU/HDU
   • ABC assessment.
   • Give supplemental oxygen. Intubate and ventilate early if airway compromise, severe hypoxemia, fatigue, altered sensorium, or severe metabolic acidosis with impending respiratory failure.
   • Obtain two large-bore IV lines. Insert arterial line when feasible, without delaying treatment.
   • Continuous ECG, SpO₂, BP, temperature, urine-output monitoring. Insert urinary catheter.
2. Investigations, without delaying treatment
   • Blood cultures from two sites before antibiotics if this causes no meaningful delay.
   • Culture suspected source: urine, sputum, wound/drain fluid, CSF, etc.
   • CBC, renal and liver function, electrolytes, glucose, ABG/VBG, serum lactate, coagulation profile, blood group and cross-match.
   • Imaging directed to source: chest radiograph, ultrasound, CT, echocardiography if myocardial dysfunction or another shock state is possible.
   • Repeat lactate to assess response.
3. Give empiric IV antimicrobials immediately
   • In septic shock, administer broad-spectrum antimicrobials ideally within 1 hour of recognition.
   • Cover likely Gram-positive, Gram-negative, and anaerobic organisms according to source, local resistance patterns, recent healthcare exposure, immunosuppression, and prior antibiotics.
   • Consider MRSA coverage when indicated. Add antifungal treatment only when risk factors and clinical context support invasive fungal infection.
   • Use initial loading doses and adjust subsequent doses for renal/hepatic function and therapeutic drug monitoring where relevant.
   • Narrow or stop therapy daily once cultures, sensitivities, diagnosis, and clinical course are known. The Surviving Sepsis Campaign guidance supports immediate antimicrobials in possible septic shock and daily review for de-escalation.

Hemodynamic resuscitation

1. IV fluids

• Give balanced crystalloid, such as Ringer lactate or Plasma-Lyte, as first-line fluid.
• Initial suggested volume: at least 30 mL/kg IV crystalloid within the first 3 hours for sepsis-induced hypoperfusion/septic shock.
• Reassess continuously rather than giving unrestricted fluids:
  • MAP, heart rate, capillary refill, skin temperature, mental state
  • Urine output target: ≥0.5 mL/kg/hour
  • Lactate trend
  • Passive-leg-raise response, bedside echocardiography, stroke volume or pulse-pressure variation if available
  • Signs of overload: lung crepitations, raised JVP, pulmonary edema, worsening oxygen need
• Use smaller boluses and closer reassessment in heart failure, CKD, or pulmonary edema. After initial resuscitation, avoid fluid accumulation and consider de-resuscitation/diuresis once shock has resolved.

2. Vasopressors

• First-line: norepinephrine infusion
  • Titrate to MAP ≥65 mmHg.
  • A higher individualized MAP may be reasonable in chronic hypertension or when perfusion remains poor despite MAP 65.
• Second-line: vasopressin
  • Add fixed-dose vasopressin if norepinephrine requirements are escalating, rather than only escalating norepinephrine.
• Third-line: epinephrine
  • Add if MAP remains inadequate despite norepinephrine plus vasopressin.
• Avoid dopamine routinely because of arrhythmia risk. Consider it only where norepinephrine is unavailable or in selected patients with marked bradycardia and low arrhythmia risk.
• Dobutamine may be added when there is persistent hypoperfusion with low cardiac output or septic myocardial dysfunction despite adequate MAP and volume status.

Source control

• Drain abscess or empyema
• Debride necrotizing soft-tissue infection
• Remove infected intravascular lines or prosthetic material if feasible
• Relieve biliary or urinary obstruction
• Operate for perforation, ischemic bowel, or uncontrolled intra-abdominal infection

Adjunctive and organ-supportive care

• Corticosteroid: If shock persists despite adequate fluids and vasopressors, give hydrocortisone 200 mg/day IV, either 50 mg every 6 hours or continuous infusion. Do not use it routinely in shock that responds promptly to vasopressors.
• Ventilation: Treat ARDS with lung-protective ventilation, generally low tidal volume around 6 mL/kg predicted body weight, adequate PEEP, and prone positioning for severe ARDS. Goldman-Cecil Medicine, p. 1098.
• Renal support: Start renal replacement therapy for standard indications, such as refractory hyperkalemia, severe metabolic acidosis, pulmonary edema/volume overload, or uremic complications. Do not initiate solely because creatinine is high.
• Glucose: Start insulin if glucose is ≥180 mg/dL (10 mmol/L); usual target 144-180 mg/dL.
• Transfusion: Use a restrictive strategy, usually transfusing RBCs at hemoglobin <7 g/dL, unless active bleeding, myocardial ischemia, or severe hypoxemia warrants a different approach.
• VTE prophylaxis: Pharmacologic prophylaxis with LMWH if no contraindication.
• Stress-ulcer prophylaxis: For patients with risk factors for GI bleeding.
• Nutrition: Begin early enteral nutrition once hemodynamically stabilized.
• Do not routinely use IV vitamin C, IV immunoglobulin, polymyxin-B hemoperfusion, or bicarbonate merely to improve hemodynamics in lactic acidosis.

Ongoing endpoints of resuscitation

Concise exam-style algorithm

Adult Septic Shock Management Algorithm

Septic shock: Suspected/confirmed infection with hypotension and tissue hypoperfusion, requiring vasopressors to maintain MAP ≥65 mmHg despite adequate fluid resuscitation.
Action: Treat as a time-critical ICU emergency.

SUSPECT SEPTIC SHOCK
↓
Activate sepsis pathway, call senior/ICU team, ABCDE assessment
• Oxygen; secure airway/intubate if respiratory failure, exhaustion, low GCS, or severe hypoxemia
• Cardiac monitor, SpO2, frequent BP or arterial line, temperature
• 2 large-bore IV lines; urinary catheter; monitor hourly urine output
↓
WITHIN 1 HOUR: RESUSCITATE AND INVESTIGATE IN PARALLEL
• Measure lactate and repeat if elevated
• Blood cultures ×2 and culture likely source, if this does not delay therapy
• CBC, electrolytes, renal/liver function, glucose, coagulation, ABG/VBG
• Imaging directed at likely focus: CXR, ultrasound, CT, echocardiography as indicated
• Give broad-spectrum IV antimicrobials immediately, ideally within 1 hour
↓
FLUID RESUSCITATION
• Balanced crystalloid: 30 mL/kg IV within first 3 hours
• Use smaller aliquots and reassess more frequently if heart failure, CKD, or pulmonary edema
• Assess fluid responsiveness dynamically:
  passive leg raise, stroke volume/echo, pulse-pressure variation where appropriate
• Avoid fluid overload. Consider albumin only after large crystalloid requirements.
↓
IS MAP <65 mmHg OR IS HYPOPERFUSION PERSISTENT?
                  ├─ NO → Continue reassessment and treat infection source
                  └─ YES
                       ↓
VASOPRESSOR SUPPORT
• Start norepinephrine: first-line agent
  - May start through a suitable, closely monitored peripheral IV while central access is arranged
  - Titrate to initial MAP target ≥65 mmHg
• If escalating norepinephrine requirement: add vasopressin
• If still hypotensive: add epinephrine
• If low cardiac output/myocardial dysfunction with persistent hypoperfusion:
  consider dobutamine with norepinephrine
↓
SOURCE CONTROL - AS SOON AS FEASIBLE
• Drain abscess/empyema
• Debride necrotizing infection
• Remove infected line/device after alternate access obtained
• Relieve biliary or urinary obstruction
• Surgery/interventional radiology for perforation or intra-abdominal source
↓
PERSISTENT VASOPRESSOR-DEPENDENT SHOCK?
• Hydrocortisone 200 mg/day IV
  (50 mg IV every 6 hours or continuous infusion)
↓
ONGOING ICU CARE
• Reassess perfusion: mental state, capillary refill, skin perfusion, serial lactate
• Urine output target: ≥0.5 mL/kg/hour
• Oxygen/ventilatory support; use lung-protective ventilation if ARDS
• Insulin if glucose ≥180 mg/dL; usual target 144-180 mg/dL
• Restrictive RBC transfusion strategy: usually Hb <7 g/dL,
  unless bleeding, acute ischemia, or severe hypoxemia
• Renal replacement therapy for conventional indications
• VTE prophylaxis, stress-ulcer prophylaxis when indicated, early enteral nutrition
• Daily review: cultures, antibiotic de-escalation, duration, source control, fluid balance